Table 1. End of Life Timeline: Signs, Symptoms, and Interventions as Death Approaches (Continued) Signs and Symptoms Interventions Last hours of life ● Body temperature changes Patient may become febrile ● Irregular breathing patterns can occur ○ Tachypnea, apnea,
● Counsel family about the signs of impending death so not to be alarmed; let them know their presence helps ○ Remind the family of the belief that hearing may still be intact until death and encourage them to talk to their loved one ● Monitor body temperature; cover patient with light sheet/blankets depending on value ○ Consider the use of antipyretics (physician order required) to prevent or treat fever, especially if causing patient discomfort ● Provide oxygen as required for comfort ● If patient becomes anxious or uncomfortable with breathing, consider the use of pain medication (morphine) or anti-anxiety mediation (orders required for both) ● As mouth breathing becomes more noticeable, provide frequent oral care ○ Clean and moisten (or remove) dentures as necessary ○ Provide ice chips or small sips of water; use moist oral sponges if patient cannot swallow ● Remove any accumulating oral secretions by positioning patient on their side and suctioning gently ○ Consider the use of medication (order required) such as Glycopyrrolate or Scopolamine to dry secretions ● Perform assessment of body and pronouncement of death per policy ● Provide comfort and support to family; encourage family to be with the deceased as appropriate ● Perform postmortem care ● Discuss and inform the family about next steps (calling funeral home, death certificate, belongings) ● Allow for members of the interdisciplinary team to say goodbye to the deceased as appropriate ● Complete all required documentation per policy
Cheyne–Stokes (period of deep, rapid breathing followed by slowing or apnea) ● Noisy breathing can occur and is typically caused by inability to clear secretions ● Changes in swallowing; Secretions in their mouth ● Slowing pulse and or changes in circulation (cyanosis/mottling) ● Confusion, restlessness, or unconsciousness ● Vision changes ● The patient cannot be awakened, is unresponsive to stimuli ● The patient stops breathing and their heartbeat stops ● Their eyelids may be partially open with the eyes in a fixed stare ● Their mouth may fall open slightly as the jaw relaxes ● Body fluids (urine or stool) may be released as muscles relax
When death occurs
● A person’s report of an experience as pain should be respected. ● Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being. ● Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.” In hospice and palliative care, the comprehensive pain assessment is performed and documented by a registered nurse (RN) on admission and then with each visit or patient contact (ANA & HPNA, 2021). In addition to the nurse, all IDT members are trained to assess pain upon each visit with the patient. For patients who can self-report or who have family present, this includes rating pain on a linear scale (numeric or FACES) and following the PQRST (Palliative/Provoking Factors, Quality of Pain, Radiation of Pain, Severity of Pain) (assessment (Table 2).
(CCH, 2021; De Swardt & Fouché, 2017) As quality of life is the most important goal of hospice and palliative care, having knowledge regarding pain as well as the skill to conduct a comprehensive pain assessment is imperative to the delivery of care. In 2020, the International Association for the Study of Pain revised the definition of pain to “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” (Raja et al., 2020, p. 1). In addition, the new definition includes six points that provide context to the experience of pain. These are (Raja et al., 2020, p. 1): ● “Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors. ● Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons. ● Through their life experiences, individuals learn the concept of pain.
Table 2. The PQRST Pain Assessment Letter
Question(s) to Ask Patient and/or Family Member What causes the pain? What makes it better? Worse?
P = Palliative/Provoking Factors
Q = Quality of Pain
What does the pain feel like (e.g., sharp, burning, stabbing, dull)?
R = Radiation of Pain
Does the pain radiate to other areas? If so, where?
S = Severity of Pain
How severe is the pain on a scale of 0–10? (Other intensity scales can be used.)
T = Temporal Factors/Timing
When did the pain start? How long does it last?
Note: (Aus Med, 2021)
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